Posts Tagged ‘migraine’

Synopsis: I’m a family practitioner from Sioux City, Iowa. I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went to have adventures and work in out-of-the-way locations. After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took up a part-time, 54 hour a week position with a Community Health Center. I’m just back from a working vacation in Petersburg, Alaska.

I went to breakfast with a couple of other docs. All three have worked locums and enjoyed it.

Over coffee we discussed caffeine’s medical effects.

One doc told about a patient with a racing heart (tachycardia) and diabetes. Eventually he stopped the family from bringing in 7 caffeinated sodas a day, and then the patient’s sugars normalized and the heart rate slowed.

The other doctor asked if headache had followed.

I made the observation that I can give anyone a migraine if I give them a high enough dose of coffee for a long enough time and then stop it suddenly. Then had to tell about the worst caffeine addict I ever took care of.

For the sake of this blog and the patient’s identity, I won’t say where or when I met a fellow in his early sixties with insomnia and a racing heart. On the first visit he revealed his 64-cup a day caffeine problem.

“Sixty-four cups a day?” My colleagues asked.

“Yep,” I said. “I had him taper down a dose a day, stay at a dose for two days if he got a headache. It took all summer but I got him down to zero, had him stay at zero for two weeks, then rechallenge. Two days later he was back to 64 cups a day. He just felt lousy without it. Clearly, he wasn’t wired like you and me.”

“What was his blood pressure?” one asked.

“Normal to low,” I answered, my memory making a successful leap over a long chasm of years.

“Did he have Addison’s?”

I came to a screeching halt.

Addison’s disease comes from inadequate cortisone production, a failure of the adrenal glands to produce a hormone necessary to maintain blood pressure and salt retention. The most famous Addisonian patient was JFK, and owed his signature deep tan to the disease. In the course of the last 30 years I have managed a handful of cases (one found by a really sharp psychiatrist) but diagnosed none.

I had to admit I hadn’t considered the diagnosis at the time but I should have.

Then I had to recall lessons learned from managing blood pressure in a suspect pheochromocytoma (docs shorten it to “pheo”) patient.

This disease involves a tumor of the outer adrenal gland, the part that puts out adrenaline. We spent lecture after lecture in med school on the subject. With a case rate of 3 per million, though, primary care doctors can tell when they arrived by the time it takes them to see a case. It took me 30 years.

We talked about alpha and beta blockade, and a drug only used for this vanishingly rare disease.

But we also talked about negotiating, game theory, decision making with imperfect information, the origin of the Syrian nerve gas, Sarin (probably Iraq), Israel’s precarious position, hospital politics, our respective future plans, and problems with Obamacare.

We didn’t always agree, but when we finished we were better doctors for the colloquium.

Synopsis: I’m a family practitioner from Sioux City, Iowa. In 2010, I danced back from the brink of burnout and traveled for a year doing temporary medical assignments from Barrow, Alaska to New Zealand’s South Island. I’m now working at a Community Health Center part-time, which has come to mean 54 hours a week.

During my senior year of medical school I arranged to get credit for an elective rotation in acupuncture in January of 1979. I studied under a very smart non-Asian internist for a month, and learned the vocabulary and the rudiments.

Before I had passed any Boards or actually obtained a license, I did acupuncture on a friend in a time crunch. I applied a needle in each shin, close to the knee (the name of the point is Su Zan Li, but its nickname means three villages). He responded well, and worked with tremendous efficiency for the next 9 days, turning out top-notch work. The bottom dropped out of his energy three days later, and he slept for the next two days.

In retrospect, I had precipitated a hypomanic episode; his bipolarity would not be diagnosed for many years. Nor did I realize the enormity of the power of those two needles for decades.

High-quality research with acupuncture showed mixed results. A study published in a major journal demonstrated very good results in treatment of the most severe alcoholics (regretfully, the study didn’t detail exactly where needles went nor how they were placed). Another, published in JAMA, showed acupuncture and sham acupuncture equivalent in the treatment of migraine. Many docs point to that study and assert acupuncture has no validity; I look at the same data and conclude that you don’t have to be much of an acupuncturist to treat migraine; put a half-dozen needles anywhere you want and not very deep, on a regular basis and at the end of a year the patient will have half the migraines he/she used to.

I went to my acupuncturist today for a session because I’ve been off Enbrel for three weeks. My sacroiliac joints haven’t fused despite my age, leading my rheumatologist to question the diagnosis of ankylosing spondylitis. He would like to see if my sed rate (ESR) and my C-reactive protein (CRP) go up in the absence of therapy.

I can hope for a misdiagnosis, or for news that my disease has burnt itself out, but as the days go by the pain in my spine grows. I’m now relying on the pain management skills I developed between 1967 and 2000, when I got my first injection.

I can do a lot of things to bring down the level of pain a notch or two; I can’t do anything to make the pain go away completely. When I walked away from the acupuncturist/chiropractor’s office the pain between my shoulder blades had faded by about two-thirds, and I could sneeze without grunting.

Synopsis: I’m a family practitioner from Sioux City, Iowa. In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work. In June of 2011 I joined up with the Community Health Center, which provides care for the underserved. I’m now working part-time, which, for a doctor, means 54 hours a week.

Quite some time ago I attended a series of patients with porphyria, a blood disease so rare that most doctors will never see a case. When the dust settled I had successfully proven the diagnosis three dozen times. The story of the research I never published and why I would even think to look in a particular bunch of selected patients would take pages and would only interest a small handful of people who probably would never think to look at my blog.

I learned that if a doctor reads for four hours about a disease, he or she will know more than half of the doctors. Eight hours of study will bring one to a state of knowledge greater than 80%, and sixteen hours will put a physician in the bottom half of the top ten percent. But to get to the top of the top requires years of study and clinical experience.

No doctor can know everything about everything, though one of my colleagues comes close (he has good social skills, too, and if we could clone him I’d be out of a job). Average front line docs have, on average, about the same level of knowledge. I really, really like hospital work because it makes me talk to doctors who know more than I do.

Most of the specialists and subspecialists I deal with approach the knowledge gap gently, and every conversation brings me to a richer state of learning. Once in a while, I get to push the knowledge flow the other way.

An excellent conversation over mediocre hospital food with a cardiologist started with discussion of the fine points of managing heart attacks, and brought us to a discussion of beta blockers, a class of blood pressure drugs that interfere with some of the actions of adrenaline. Labetalol rates favorite status among some of the docs, he said. I pointed out that it cost more than any other generic in the class; carvedilol, the most recently generic of the group, costs the least. I looked at the priceless expression on his face and explained that I’d just talked with one of the Community Health Center pharmacists.

Then we talked about propranolol, the oldest beta blocker of them all. The cardiologist mentioned that men won’t take it because of sexual dysfunction, I talked about how I prescribe very low doses to treat premature ejaculation.

While the cardiologist listened, I held forth about propranolol’s uses having nothing to do with its original indication, hypertension. His interested escalated when I got to migraines, which led me to sleep and thence to jet lag.

No reason, I asserted, to have jet lag in the 21st century. A simple sequence of five drugs would multiply the effective days of vacation.

In the course of twenty minutes, I learned more cardiology, he learned a good deal about sleep management, and we both walked away better doctors.

Synopsis: I’m a family practitioner from Sioux City, Iowa. Taking a sabbatical to bounce back from the brink of burnt-out, while my one-year non-compete clause ticks away I’m having adventures and working in out-of-the-way places. I’ve just finished seven weeks in Wellsford, north of Auckland, on the North Island of New Zealand

My last day in the Wellsford/Matakana area came wet and rainy. I breakfasted on clean-out-the-fridge and leftovers. With my improved NZ driving skills the morning commute only took me 34 minutes.

Drama and irony ruled the day.

I took care of two patients with dog bites, and while I examined them and filled out the ACC45 form, I listened to stories of unexpected violence and betrayal.

I fielded two requests for inappropriate medications. One explanation: abusing one drug doesn’t warrant a prescription for another easily abused drug. Another involved a pharmaceutical known to aggravate migraines in a patient with worsening migraines; when I denied the request I realized that the situation’s complexity ran deep. Saying “no” cost more time than the rest of the visit put together.

A patient with a low-grade skin malignancy incompletely removed on shave biopsy refused to come in for complete excision, wanting to wait to see what happens.

I saw three cases of impetigo

At lunch the rain had stopped and I ran into another doc at the Tangiers Cafe. We had a great time discussing cases and demographics. The world can’t sustain current human growth without fossil fuels, we agreed, peak population will hit about 2050, after that the religious extremists will populate the world. The doom and gloom didn’t keep us from enjoying our Mississippi Mud chocolate cake afterwards, nor did it dampen my appreciation of the dramatic sky on the walk back, clear blue and sunny to our left; dark, and threatening to our right, with a gentle warm drizzle.

A patient requested chronic pain relievers, to my surprise specifying Panadol (= American Tylenol) and a non-steroidal anti-inflammatory drug (NSAID). Of course I said yes, glad I politely asked, “What would you like?” not, “Let’s get this straight, I don’t prescribe narcotics for back pain.”

Throughout the day, nurses and other staff came in to give me good-bye hugs.

On two occasions I said, “I don’t think you have a medical problem that warrants an income from the government, but, hey, it’s my last day and you can come back next week and ask someone else.”

A patient told me that the current relationship involved an alcoholic, bipolar, drug-abusing, sex-addicted partner but didn’t involve love. I advised saying, “Don’t come back till you’re on medication and in AA for six months.”

When the pharmacy called I realized I mixed up names of the last two scheduled patients. A flurry of paperwork always accompanies the last hours of a clinical tenure, and while I struggled to set the two prescriptions right and get the last few items signed, a nurse poked her head in.

Sometimes Americans begin a request with “Would you mind…”; Kiwis use “Would you be happy to…” I strode over to the curtained cubicle where I could feel a patient’s fracture. Appropriate management had already started. The requested medication constituted a lower potential for abuse; I walked the prescription over to the nurses’ area.

I left the clinic in the rain, saying goodbye to seven weeks of a rollicking good time.

I had a great last day, making six great last days in the last year, but I don’t want to be an expert at it.

I drove back to Matakana in the pouring rain and the deepening twilight. Bethany and I ate Greek salad, garlic bread, and dessert at the Rusty Pelican. Our packing process efficiency improves with each move; Bethany does most of it. A torrential downpour over night produced a noisy overflow from the water storage tank, and 3 of the 5 hours we devoted to sleep went well.

Unexpected time lost to a sticky garage door ate into planned get-lost minutes, but we dropped the rental car at the airport and arrived at the train depot ahead of schedule.

We enjoyed the twelve-hour train ride. We napped and snacked and talked and joked. We agreed that taking the train showed us more scenery than the plane and gave us more relaxation than driving. A storm hit at sunset, with winds so violent the train rocked.

A lot of bipolar disease masquerades as depression, though depression runs rampant in twenty-first century America (elsewhere, too). I start to suspect bipolar if the patient has been on more than three antidepressants, if there’s a family history of severe mental illness (institutionalization, or suicide), or if a particular antidepressant works for a while, then stops working.

What doctors and the popular press used to call manic-depression now carries the label of bipolar. Seventy-five percent hereditary, it runs in families. Everyone has good days and bad days, but bipolar patients cycle between extremely great moods and profound depression. Every day spent feeling good brings an average of four days feeling down. While manic they may feel invulnerable and engage in risky behavior, ruining their family relationships, finances, and health; while depressed they may commit suicide.

If I suspect the patient of being bipolar, I ask, “Have you ever had an episode lasting at least four days when you felt great, got a lot done, slept less than four hours a night, and didn’t miss the sleep?” A yes answer confirms the diagnosis though a no doesn’t exclude it.

The textbooks break bipolar disease into the more severe bipolar I and the less severe bipolar II, but I think the disease runs a spectrum. Diagnosing the extreme cases comes easily, less severe disease is more subtle.

A few days after my arrival in Barrow I diagnosed a patient as bipolar; at the time she was compulsively picking at herself. I recommended she change her current antidepressant (a selective serotonin reuptake inhibitor or SSRI) and start topiramate or Topamax. Of course the drug is not on the formulary and I had to get special approval to prescribe it.

You can’t just start taking Topamax; the dosage starts low and gets increased slowly. The medication has a lot of side effects, one of which is appetite suppression. Its tolerability ranges widely. Currently under investigation by the FDA for approval for the indication of weight loss, people lose an average of thirty pounds when they take it.

The FDA approved it for use in bipolar disease, migraines and seizures; my impression has been that it’s good at damping binge eating.

They say the young doctor knows twenty drugs that will treat one disease, and the old doctor knows one drug that will treat twenty diseases. The choice for Topamax was a clear slam-dunk for the patient, who gave her permission to give this information.

She was in today. She stopped picking at her breasts, face and nails, those sores have healed. She lost about fifteen pounds so far, and she’s a lot happier. We agreed making an appropriate diagnosis of bipolar disease is a worthwhile goal because it leads to a different, more effective treatment.

My background is littered with bipolar people. In high school my jazz trio turned out to consist of a bipolar drummer, a bipolar pianist, and me.

I had a good time in music back then. I didn’t see music as an end in itself, I thought it could be a means to a living, and if you have great business sense, great musical talent, and great luck, it can be. I lacked the talent and I lacked the desire to practice enough to maximize the talent I had.

Here in Barrow, closer to the North Pole than to the state capital, I have found very good musicians to hang out with. Shortly after I got here I was recruited into the band Synergy, and I’ve been practicing hours a day and loving it.

Eight weeks ago, half an hour of practice exhausted my lips.

Today I played half an hour in the morning, another half hour in the afternoon, and we just finished a three hour gig at Pepe’s North of the Border. It was our swan song.

Our trumpeter will be going south for the summer; long before he comes back I will have left.

We played seven gigs together. In the time I’ve been here my lip strength has improved; I have my chops back. In the last number of our last gig I played well; I had control of my reed, the notes were under my fingers.

We were the last customers at the restaurant. I had a steak afterwards; the French fries were excellent but the beef wasn’t up to Iowa standards (won’t I ever learn?). Our trumpeter and his wife, my wife and I, the guitarist and the vocalist sat over pie and ice cream and chatted with Fran, the owner of Pepe’s, who deserves her own post or five.

In the fog that follows an all-day and all-night rain, we piled the equipment into the taxi, but most of us walked from the restaurant to the guitarist’s house and then back to the hospital.

I had my first migraine when I was 26. I’ve had three since. I figured out the circumstances precipitating the event and I have avoided them.

When the first one hit I thought I was having a stroke. The beautiful flashing lights puzzled but did not displease me; I didn’t have the medical background at that time to be able to give them their proper name, scintilliating scotoma. Most of the left half of my vision blanked out, and, as a second year medical student at the time, I thought to myself “left-sided bilateral hemianopsia.” Then the nausea and the blinding, hammering pain started and made me sure, for about two hours, that I would end up crippled if not dead. After the pain left and I got back to Michigan and out of a sociologically hostile environment, I figured out I’d had a migraine.

My sister had been having them for years.

I had my next migraine my first week as a third year med student in Saginaw, Michigan, during a gratuitously hostile instructional session. We were supposed to learn how to do peripheral smears of our own blood, but mostly the lecturer convinced us of our dangerous incompetence.

I have taken care since then to bring an ally with me if I go someplace hostile, and I’ve only had one migraine since.

I still get the aura, the neurological warning shot across the bow. The beautiful yellow and blue lights, spread slowly in shimmering bars in a semicircle across my vision. Most of the time I have to keep working, but on two occasions I’ve been able to just kick back and shut my eyes and watch the light show.

The experience gave me sympathy for people with migraines. It also taught me to approach the problem by teaching avoidance of triggers.

On the other hand, I don’ t have a lot of patience for people who keep doing things to get migraines and then ask me for Vicodin, Percodan, or Lortab.

Diagnosis of migraine properly would take about ten pages, and remains far from simple.

(I had a patient with a long history of migraines that experienced a change in headache pattern, and only because I listened well could I determine the necessity of an MRI, which in turn led to treatment and thus avoided death. Another patient with more talent for dramatics than communication needed a sequence MRIs and a really, really sharp neurologist colleague to find three aneurysms. The pathological evaluation showed giant cell arteritis inside two of them. The patient fired me anyway.)

If I have a firm diagnosis of migraine, I divide the current frequency by four, and ask the patient if that would a “good enough” goal; most respond enthusiastically in the affirmative, and we talk about triggers:

Nicotine. Of course I tell smokers to quit, but especially migraineurs. Some express surprise on hearing that nicotine causes migraines

Caffeine. A distressing percentage of migraines are really caffeine withdrawal headaches. To put it another way, caffeine relieves the headache only because the person hit the caffeine withdrawal threshold. I tell the patient to cut the caffeine intake by one dose per day till they get to zero, and then avoid caffeine completely for 2 weeks, then rechallenge. Most don’t rechallenge.

Alcohol. Yes, strangely, hangovers include headaches. Some people only have their migraines after drinking.

Sleep. Too much or too little sleep can precipitate migraine in a lot of people

Nutrasweet. Just one more reason to avoid artificial sweeteners.

Cheese. This low-item applies to a very small minority of migraine sufferers

Hot dogs: This is an even lower yield item. Most people who get the hot dog headache know it before they get to me and have stopped eating hotdogs.

Hormonal Birth Control: Bad migraines in the presence of prescribed hormones greatly increases the risk of disabling stroke. Thus I ask about migraines (and other things) before I prescribe birth control pills. Or patches. Or shots. Or rings.

Pain reliever overuse. People sometimes get into a cycle of using increasingly frequent doses of ibuprofen, acetaminophen, naproxen, or aspirin to stop the headaches, and don’t realize that so much analgesic use leads to worsening migraines. Those cases can be very difficult to treat, and on occasion I’ve hospitalized patients to do so.

Ninety percent of my migraine patients get to goal with no medication.

Ninety percent of the rest get to goal on 10 to 20 mg of propranolol a day.

After that it’s a toss-up between other daily medications and acupuncture.

A very few patients can tolerate no migraines at all, and they get prescriptions for triptans.

If a patient shows up with a migraine in progress, I order a 60 mg injection of ketoralac.

One of my medical school classmates said, in 1978, that he didn’t want to go into primary care because he didn’t want to just take care of sore throats and runny noses.

Just before bed last night I logged onto the lab queue. Six patients blinked in red from the icon at the lower right corner. A seventh blinked in black.

Vitamin D deficiency is rampant, and of the six patients with abnormal results, five had low Vitamin D levels, one critically low at 7.5, the lower limit of normal being 33. One set of lab values gave a new diagnosis of rheumatoid arthritis, another a case of hepatitis C.

I see so many people who just don’t feel good that twelve years ago I specified a group of lab tests: CBC, sedimentation rate, B12/folate, thyroid, Chemistry 14, and hepatitis C; I named the panel the GFMP (Gordon’s fatigue and malaise profile). I put it together right after I’d gotten a lot of propaganda from the Hepatitis C Foundation. Three years ago I started checking Vitamin D levels. In all that time I picked up exactly two cases of hepatitis C, and both of them were found by sleuthing down abnormal liver function tests. In this new case, the liver functions were normal, along with the rest of the panel.

Of historical note is that hepatitis C didn’t even get identified till after I’d finished residency. There was nothing to do about it for years; now we’re running a 50% cure rate, cutting into the number of people needing transplants.

I sent emails to the phone nurse pool, to be opened up in the morning; get viral load and viral type on the Hepatitis C, send the rheumatoid patients’ lab work to the rheumatologist, and start all those Vitamin D deficieny patients on bold doses of the sunshine vitamin.

I get a call at about 9:30 AM from a hunting buddy who is connected to me at least three ways. A friend of his has bad migraines and isn’t getting very far with the other docs and would I be willing to work the friend in?

I ignore the fact that I have had bad consequences because I don’t say No well, and I say yes.

I find a hole in my schedule at 11:30, and I tell my nurse.

Three other holes that don’t exist get filled before 11:30 and I don’t start with the new patient till 12:20.

Ninety percent of my migraine patients get successfully managed with life style modification. For all you migraine sufferers out there, here goes: Eliminate nicotine, caffeine, alcohol, Nutrasweet, cheese, and hotdogs. Get into a rigid, effective sleep pattern. By the time I individualize details for this migraine patient (for example, move the TV out of the bedroom, quit smoking with Chantix, and taper down the caffeine) it is ten minutes to one, when the afternoon patients start up, and my documentation is 12 charts behind.

Oh, yeah, and I arrange an MRI for her because she’d never had one and her headaches are getting worse.

I bolt my lunch in five minutes and I’m hacking away at my computer, putting in documentation.

Eventually I hope to get control of my schedule, but I know that it won’t happen till I start saying No.

I’ve gotten better. Four times today when patients tried to put more than four problems on their list I gently made them put together a realistic agenda, and encouraged them to come back at a later time. I didn’t tell them how trying to pour gallons into teacups strains me, puts me behind so the other patients get mad. I just said boy, that’s too much for one day, but it’s really important, can you come back Tuesday?

I still fall into unrealistic time management thinking more than once a day.